Cross-donor system planned for region's kidney patients

By Scott Allen, Globe Staff | June 5, 2004

New England transplant surgeons, working with a Harvard economist,
are planning a unique organ-trading system that could ease the shortage
of kidneys available for transplant by giving willing donors a strong
new incentive to give their kidneys to strangers.

Currently, hundreds or even thousands of potential organ recipients
must join a long transplant waiting list even though friends or family
members are willing to donate a kidney, because the would-be donors
prove to be a poor match with the patient. The new system would take
these willing donors and connect them with similarly mismatched donors
elsewhere in New England, allowing them to cross-donate kidneys to each
other's friends or loved ones.

Since 2001, New England doctors have performed six of these paired
exchanges, including one last year when two women each successfully
donated a kidney to the other's husband at Massachusetts General
Hospital. But the idea's effectiveness is limited by the difficulty of
finding well-matched patients and donors.

To overcome this, Harvard economist Alvin Roth developed a new
computerized donor tracking system that could allow doctors to arrange
scores of exchanges per year in New England alone, over time
significantly reducing a regional kidney waiting list that now stands
at 2,237. In a limited test of his system, Roth found eight matches
from 45 potential donors who had previously been rejected. Applied
nationally, Roth believes the system could potentially save thousands
of lives.

''This could be quite a substantial increase in the number of live
donors," said Dr. Francis L. Delmonico, medical director of the New
England Organ Bank in Boston, which manages the region's organ supply.

The paired-exchange system appears to be surmounting the ethical
concerns that have sunk other ideas for fostering more organ donation.
Congress long ago barred financial incentives to encourage donors, but
medical ethicists are also concerned about any system that pressures
people to undergo a risky operation that does not benefit their own
health. Though most organ donors recover fully, an estimated one in
3,000 die and all of them lose their backup kidney in the event they
develop kidney disease themselves.

Writing in The New England Journal of Medicine recently, Delmonico
argued that organ exchanges can be ''models of altruism" as long as
everyone knows the risks and no money is involved. A transplant surgeon
at Mass. General, he has proposed Roth's matching system to the panel
of surgeons that sets kidney transplant policy in New England.

''I don't think that there are any ethical issues" to expanding the
number of trades, said Dr. Paul Morrissey of Rhode Island Hospital,
chairman of the Renal Transplant Oversight Committee. ''It's just
setting up the mechanism to carry it out."

Even tough critics such as Dr. Lainie Friedman Ross, medical
ethicist at the University of Chicago, agree that the paired-exchange
system can be fair. Ross has faulted other approaches for
discriminating against one group of patients in favor of another, but
she said she's ''totally in favor" of Roth's system.

The paired-exchange system comes 50 years after Dr. Joseph Murray
carried out the nation's first kidney transplant at what is now Brigham
and Women's Hospital, using a kidney taken from the patient's identical
twin to avoid organ rejection. Today, in part to antirejection drugs,
surgeons can often transplant kidneys between perfect strangers even if
the donor's tissue is a poor match.

As a result, almost a quarter of live donors are not related to the patient who gets their kidney.

Roth estimates that nearly half of willing donors do not donate
because their blood type doesn't match the patient or the patient's
immune system would attack the donated organ, and because there is
currently no system for keeping track of rejected donors.

Roth's system would change that by entering potential donors' names
into a computer database and searching for a match. Long interested in
improving the transplant system, Roth has written a detailed paper with
two other economists outlining how the system will work.

With the kidney transplant waiting list now up to 61,000 across the
country, transplant surgeons and patient groups will be watching the
New England experiment closely. Morrissey said the system is sure to
save lives, but ''whether it adds 15 transplants a year or 150 remains
to be seen."

In recent years, surgeons have become increasingly desperate for
transplant organs, with some even suggesting that people get paid to
fill out an organ donor card.

So far, the handful of paired exchanges completed in New England
have created happy endings for people who were increasingly hopeless.

For instance, Susanna Polletta of Watertown, Conn., had wanted to
donate a kidney to her husband, Rosario, whose kidneys were gradually
failing as a result of a long battle with lupus.

But both her blood and tissue types were a complete mismatch for
him, so Rosario remained on a transplant waiting list for years,
relying on home dialysis to keep his body going.

By chance, Rosario's doctor at Mass. General, Nina Rubin, was
treating another man who had the same problem: Tracy Scott of
Chichester, N.H., was languishing on the transplant waiting list even
though his wife, Robin, was ready and willing to donate a kidney. Then
Rubin discovered that Robin's kidney was a match for Rosario while
Susanna's matched Tracy's. ''It was like a miracle," said Rosario
Polletta.

On Feb. 25, 2003, the women donated their kidneys to the two men,
and, 15 months later, all four have resumed their normal lives.

''I probably have more energy now than I did when I was 30," said Polletta, now 47.